On May 18, 2026 (yesterday), South Africa’s Constitutional Court unanimously upheld a 2024 ruling from the Pretoria High Court, declaring Sections 36 to 40 of the National Health Act 61 of 2003 (NHA) unconstitutional and invalid.
QuickNews previously reported on the High Court judgement, which you can read about here. The Certificate of Need (CON) was part of 2003’s NHA, which was never implemented. Despite it not being a part of the 2023 NHI Act, the removal of the Sections was seen as undermining a core pillar of NHI – centralised management.
The case was brought by Solidarity Trade Union, the Hospital Association of South Africa (HASA).
It was argued that the CON unfairly constrained the rights of doctors to practise where they chose, and hospitals and other healthcare facilities would not be able to operate without one, nor for new facilities to open or even expansions to be made. The provisions, which aimed to promote equitable distribution of healthcare services, had not yet been implemented.
The Director-General of Health, who issued the CON, would have had exercised a “blunt instrument” to control private healthcare in the country, noted Judge Anthony Millar of the Pretoria High Court in his judgement.
The sections were found to be irrational and an unjustifiable limitation on the constitutional right (Section 22) to freely choose a trade, occupation, or profession. They granted overly broad discretionary powers without adequate safeguards. Finally, the court ruled that severing (removing) these sections entirely from the NHA was appropriate, with no need to refer them back to Parliament for fixing. The Health Minister and Director-General were ordered to pay costs.
Anton van der Bijl, Deputy Chief Executive of Solidarity, said: “The Certificate of Need was far more than merely an administrative instrument. It was an instrument of centralisation and state control.”
The Constitutional Court’s hearing over National Health Insurance (NHI) concluded on 7 May. The Board of Healthcare Funders (BHF) and the Western Cape Provincial Government made a combined application challenging the NHI Act on public participation grounds.
The Court is now deliberating; on such complex constitutional matters, it can be weeks to months before a judgment is made. The implementation of NHI remains suspended, following February’s High Court order – President Cyril Ramaphosa and the Minister of Health have formally undertaken not to proclaim or implement any part of the act until the Constitutional Court’s ruling. Other legal challenges are now paused.
What were the arguments?
The hearings focused on one key question: whether Parliament’s process met the constitutional threshold for public participation (primarily under Sections 59 and 72 of the Constitution). Section 59 mandates proactive, reasonable, and meaningful public engagement for the country’s participatory democracy. Formalities alone do not satisfy it – rather, the test is contextual reasonableness aimed at genuine influence. Constitutional Court challenges for national legislation are the main means by which Section 59 is enforced.
The BHF argued that hundreds of thousands of written submissions were effectively ignored; critical information was not provided; and whether, without such information, the test for rational law-making was met.
The Western Cape (led by Premier Alan Winde) focused primarily on deficiencies in the NCOP and provincial stages of the process, arguing that these violated constitutional public-participation requirements and undermined provincial roles. For example, the NCOP process was compressed into only eight weeks, key inputs were ignored, and provincial roles were undermined.
Parliament contended that the process was far more than a “tick-box” exercise, presenting the NHI to the public as a radical, transformative process and that details would only emerge as the project proceeded. [Nevertheless, even a simple calculation would show an NHI budget of R200bn, requiring crippling taxation.] They also argued that accommodations were made, such as extending written comment deadlines. They also argued that changes were made to the Bill, and that engagement does not mean that the legislature agrees, but rather is informed.
Judges raised questions about the integrity and practicality of the public health system in the context of NHI, but the core legal issue remained procedural compliance as opposed to the policy merits.
Is there precedent?
This would not be the first time the Constitutional Court has set aside Acts. In 2006, in a case brought by Doctors for Life, the Choice on Termination of Pregnancy Amendment Act and Traditional Health Practitioners Act were invalidated as Parliament had failed to comply with its section 72(1)(a) constitutional obligation to facilitate public involvement before passing.
Further cases reinforced that inadequate information, rushed timelines, and a lack of consultation over major changes would result in a breach. Parliament, however, argues that Doctors for Life shows that the requirement for participatory democracy has been met.
All parties now await the Court’s decision, which could either uphold the Act, declare it partially or wholly invalid, or remit aspects back to Parliament for correction.
By Gale Shabangu, Chairperson, Hospital Association of South Africa (HASA)
Recently, President Cyril Ramaphosa made an important decision: to pause the promulgation of the National Health Insurance (NHI) Act until the Constitutional Court has ruled on the pending challenges to Parliament’s role in passing the Act. In doing so, he affirmed that due process must guide reform.
It is a reminder that healthcare reform is not a race to the finish line, but a journey that requires careful pacing, broad consultation and respect for the voices of South Africans. Reform at this scale is like tending a vast garden: every seed must be planted with foresight, every path cleared with care, so that the harvest nourishes all.
Families already feel the strain of rising costs – electricity, food, borrowing – and medical contributions that climb steadily. Yet even in this pressure, there is resilience. South Africans have always found ways to adapt, to share, to build together. Healthcare reform must honour that spirit, ensuring affordability is not a privilege but a shared foundation.
The private healthcare system is a necessary and valuable part of the scaffolding of our healthcare system, sustaining capacity that millions rely on. Unfinished reforms, such as risk equalisation, mandatory membership, and base benefit packages, remain like bridges half‑built. Completing them would stabilise participation and strengthen the entire ecosystem.
If private participation declines, demand does not vanish – it shifts. Public hospitals, already carrying immense responsibility, would feel the weight. Yet here lies the opportunity: to recognise that public and private healthcare are not adversaries but allies. The public sector anchors universal access; the private sector provides funded capacity that absorbs demand and sustains innovation. Together, they form a single ecosystem, each part vital to the whole.
Healthcare reform is about weaving our systems together into a fabric strong enough to carry us all.
As the President recently noted, readiness is central to bringing legislation into effect. Readiness is not bureaucracy – it is the heartbeat of reform. It signals that change must be feasible, not forced; sustainable, not symbolic. That is a hopeful message, because it means reform will be paced by practicality, not politics.
The path forward is clear and promising: complete outstanding reforms in medical schemes, strengthen risk pooling, invest in primary care and prevention, and sequence structural changes responsibly. These steps are not obstacles – they are stepping stones toward a healthier, more equitable South Africa.
Healthcare reform is a national undertaking and a shared responsibility. Government, funders, providers, employers and civil society are all custodians of this commitment. What matters now is how we act, with realism, collaboration and a clear focus on strengthening what already works.
Equitable access to quality healthcare is our shared goal. Achieving it requires evidence, readiness, and respect for complementarity. With stability, sustainability and collaboration as our compass, South Africa can build a healthcare system that is workable and inspiring – a system that reflects the resilience, dignity and hope of its people.
Healthcare requires stewardship. With stability, sustainability, and collaboration guiding reform, South Africa can build a system that works for everyone. And with optimism guiding reform, I believe we can build a system that works for everyone – today, tomorrow and for generations to come.
From 5–7 May, the Constitutional Court will hear two of the multiple challenges to the NHI Act. Sasha Stevenson, Executive Director of SECTION27, considers what will be on the line in these first potentially landmark cases that deal with the process that led to the Act.
The public discussion on National Health Insurance has gone from abstract; to alternatively excited or worried about implementation; to dizzying references to a range of court cases filed over the course of 2024 and 2025. It can be difficult to keep up with what NHI may mean for our health system and when the promised system reform may happen.
We may now be approaching a decisive moment, with the Constitutional Court set to hear two of the NHI challenges.
From 5–7 May 2026, the Constitutional Court will be hearing challenges brought by the Board of Healthcare Funders and the Premier of the Western Cape. These two challenges deal with public participation in the making of what is now the NHI Act.
In February 2026, parties challenging the constitutionality of specific sections of the NHI Act agreed with government to put their cases on hold, pending a decision of the Constitutional Court in the May 2026 public participation challenges. The parties bringing constitutional challenges include the South African Private Practitioners Forum, the Hospital Association of South Africa, the South African Medical Association, and the Health Funders Association, among others. They agreed to hold off because a decision of the Constitutional Court on public participation could make the constitutional challenges unnecessary.
So for now, all eyes are on the Constitutional Court, whose judges will decide whether government must go back to the drawing board and follow a different procedure, or whether it may go ahead (and face a slew of constitutional challenges).
The Western Cape’s case
The Western Cape government is challenging the NHI Act because it argues that consultation with the Western Cape government, over legislation that restructures health services provided by provinces, was lacking. They argue that the National Council of Provinces (NCOP) failed to respond to a request for an extension for the Western Cape to submit the outcome of its provincial consultation on the NHI Bill and its voting mandate, and then went ahead without the Western Cape documents.
The NCOP also did not, the Western Cape government alleges, consider or debate any proposed amendments to the NHI Bill arising from the public participation in other provinces. When the Western Cape government submission and public participation report came in, the NCOP merely confirmed its earlier decision to approve the Bill.
In essence, the Western Cape’s challenge is about the NCOP’s role of ensuring that provinces and their residents have a say in the making of new laws, and whether that role was properly played. It argues that the NCOP’s failure to play its constitutional role should result in the NHI Act being declared unconstitutional and invalid.
The Board of Healthcare Funders case
While the Western Cape challenge does not deal with public participation in the NHI law-making writ large, the Board of Healthcare Funders (BHF) case fills this gap.
The BHF argues that both the National Assembly and the NCOP failed to comply with their constitutional obligations to facilitate meaningful and effective public involvement in the NHI law-making process. The BHF contends that the public was not provided with sufficient information to allow for meaningful engagement (such as details about the costs and the benefits package of the NHI Fund); and that law makers were not open to persuasion in the participation process.
The BHF asks that the NHI Act is declared invalid and set aside.
Why should we care about public participation?
The Constitutional Court has held that “[i]t is apparent from the preamble of the Constitution that one of the basic objectives of our constitutional enterprise is the establishment of a democratic and open government in which the people shall participate to some degree in the law-making process.”
There was a huge amount of public participation in the law-making process for the NHI Act, with roadshows, written submissions and oral presentations. Government respondents in the BHF case point to the fact that 338 891 written submissions were made at various stages, and many oral presentations were heard by Parliament. Few could argue that, if you wanted to, you did not have a chance to have your say on the NHI Bill.
But is being able to say something enough?
In a constitutional democracy where citizens participate in law-making between elections as a way of directly influencing the law, if there is no chance of having that influence, merely being able to speak is insufficient.
There is, of course, no obligation on government to adopt proposed changes as a result of public participation. Parliament cannot be required to agree with all submissions, and the validity of a process does not turn on whether amendments were made to take into account submissions. But when few or no amendments are made, it inevitably raises eyebrows.
In the case of the NHI Bill, while there were limited changes to the Bill when it went through the National Assembly, no changes at all were made following the NCOP public participation process. Given the hundreds of thousands of submissions, many of which were substantive, the small number of amendments is surprising. Particularly given that some submissions that were consistently made are now being conceded by the Department of Health, in public or in private. These include submissions related to the position of asylum-seekers, transitional provisions, and the role of medical aids.
SECTION27 and the Treatment Action Campaign made submissions at Draft Bill stage, before the National Assembly, and before the NCOP. As health activists and health rights lawyers, our submissions were carefully considered and proposed amendments to bring the Bill in line with the Constitution and the needs of healthcare users. Our experience was of MPs engaging to a very limited extent with the substance of the submissions, focusing rather on whether we were ‘for’ or ‘against’ the NHI, or their party’s position on it. It was an experience that brought into question how seriously real public participation was being taken.
The Constitutional Court will now be able to consider whether the public participation processes on the NHI Act were in line with the constitutional call for participatory democracy; or whether they were an unconstitutional tick box exercise. Its decision will determine if the NHI Act will be further scrutinised for substantive constitutionality through litigation, or if it should be returned to the legislature for further consideration and participation.
Either way, what NHI may mean for our health system is a question that may yet take some time to answer. On the other hand, what participatory democracy requires of parliament (arguably an even more consequential question) may soon be answered by the Constitutional Court.
*Stevenson is a human rights lawyer and executive director of SECTION27. SECTION27 is representing the Treatment Action Campaign in an application to be admitted as amicus curiae in a court case relating to the NHI.
Note: Spotlight is published by SECTION27, but is editorially independent – an independence that the editors guard jealously. Spotlight aims to deepen public understanding of important health issues by publishing a variety of views on its opinion pages. The views expressed in this article are not necessarily shared by the Spotlight editors.
The public health sector serves roughly 84% of South Africans, yet per-person spending in private healthcare is around five times higher. The National Health Insurance (NHI) is designed to change that equation. As President Ramaphosa stated, the right to healthcare “cannot depend on where you were born, how much you earn or where you live.”
For patients with blood cancer and blood disorders, that promise could not be more urgent. On World Health Day 2026, Palesa Mokomele, Head of Community Engagement and Communication at DKMS Africa, says this is an opportunity to ask whether the NHI is being designed to reach them. “Blood cancer and blood disorder patients depend on highly specialised treatment pathways – exactly the kind the NHI has an opportunity to strengthen. They cannot be an afterthought in the benefit package conversation.”
The NHI Act was signed into law in May 2024 but has not yet commenced, with key constitutional challenges set to be heard in May 2026. Despite legal uncertainty, the government has been clear that foundational work will continue.
The Reality on the Ground
Stem cell transplantation is one of the most effective treatments for blood cancers and blood disorders, and among the most resource-intensive, requiring specialist physicians, trained nurses, dedicated infrastructure, and in 70% of cases, a matched unrelated donor (MUD).
The capacity to deliver these treatments is already under severe strain. Just 25% of South Africa’s oncologists serve more than 75% of the population. Long treatment delays, limited resources, high patient volumes, and advanced disease at presentation make for a deeply challenging environment.
“What we see is a system doing its best under enormous pressure,” says Mokomele. “The NHI has a real opportunity to address those structural gaps, but it requires deliberate investment where the need is greatest.”
What Universal Coverage Must Include
The NHI benefit packages for the treatment of blood cancer and disorders have yet to be finalised. With South Africa projected to see a 78% increase in cancer incidence by 2030, whether those packages cover the full cost of finding, matching, and transplanting an unrelated donor will be a test of whether universal health coverage means what it says.
“We are not here to debate the merits of the NHI,” shares Mokomele. “We are here to make sure that when it is implemented, it works for every patient. The full treatment pathway must be funded, and the clinical infrastructure to deliver it must be in place.”
President Ramaphosa has called for genuine partnerships between the public and private health sectors, academic institutions, NGOs, and communities. “That vision of cross-sector collaboration reflects exactly how we believe this challenge must be met,” notes Mokomele.
A Blueprint for Access
DKMS Africa’s Access to Transplant programme offers a practical example of barrier-free access in the public sector. Working across six provinces, it aims to invest in infrastructure upgrades at public hospitals, training for specialist nurses and mobilises its global network to collaborate with physicians, and patient support services addressing practical barriers, such as transport and housing, that often cause patients to abandon treatment.
“When you remove barriers systematically, outcomes improve,” points out Mokomele. “Each barrier removed is a patient who makes it to transplant. That is the model the NHI needs to learn from and scale.”
The organisation is also preparing for a more centralised system, ensuring its programmes can integrate into national frameworks while maintaining global standards – through early diagnosis education, donor registry diversification, stronger referral pathways, and local research capacity.
Your Health System, Your Voice
The decisions being made about the NHI benefit package today will shape healthcare for decades. Young South Africans will inherit both the growing burden of disease and the system designed to address it.
“World Health Day is a reminder that universal means everyone,” concludes Mokomele. “We are asking young South Africans to support us in uniting towards a healthcare system that works for everyone.”
ANC President Cyril Ramaphosa, with Minister of Health, Dr Joe Phaahla and his deputy Dr Sibongiseni Dhlomo, during the signing into law of the National Health Insurance Bill. (Photo: @MYANC/Twitter)
By Thoneshan Naidoo
Healthcare funding is always about trade-offs, writes Thoneshan Naidoo, CEO of the Health Funders Association. The hardest question in healthcare is not what we would like to provide, he argues, but what we can provide sustainably, fairly and at scale.
South Africa’s healthcare debate is shifting and perhaps for the first time in years, it is becoming more honest.
With the National Health Insurance (NHI) Act tied up in legal processes and no credible funding pathway emerging from the 2026 Budget, the conversation is moving away from sweeping promises about the future to a more immediate and uncomfortable question. That is how do we fund healthcare today, and what trade-offs are we willing to accept?
At the centre of that reality is a part of the system that is often misunderstood and frequently criticised – medical schemes.
They are often portrayed as profit driven and exclusionary. In reality, they are not for profit, member owned entities built on a simple but powerful principle, social solidarity. Simply put, members pool their contributions so that those who are healthy today help fund the care of those who are sick.
In practice, around 80% of members claim less than they contribute in any given year. Their contributions help fund the care of the 20% who need it most. That is not exploitation. It is the very definition of risk pooling, and it is the same principle that underpins universal health coverage.
But solidarity comes with trade-offs.
Every Rand paid out in benefits in excess of a member’s monthly contributions is funded by other members. That means decisions about what is covered, how much is paid, and when limits apply are not arbitrary. They are the result of difficult choices about what the overall pool can afford.
These trade-offs become most visible in moments of tension, when a claim is limited, a treatment is excluded, or a dispute arises. To the individual, the system can feel uncaring. But at a system level, the alternative, unlimited funding for every possible intervention, is simply not sustainable.
Even prevention, often presented as an obvious solution, is not as straightforward as it seems.
Take colorectal cancer screening. An inexpensive test such as a faecal immunochemical test can help detect disease early. But many false-positive results lead to follow up procedures like colonoscopies, even when no serious condition is ultimately found. At the same time, some cases are still missed and only diagnosed later, when treatment is more complex and more expensive.
The question is not whether prevention is valuable, it is how to fund it at scale in a way that balances early detection, over treatment and cost.
These are not abstract policy debates but are real world funding decisions that affect millions of people.
And they are taking place in a system under pressure.
Medical scheme membership is voluntary, so younger and healthier individuals often delay joining until they need care. This drives up costs for those already in the system. At the same time, schemes are required to cover a comprehensive set of 270 Prescribed Minimum Benefits, which raises the baseline cost of cover.
The result is a system that works well for those inside it but remains out of reach for many.
This is South Africa’s so-called “missing middle” – millions of working people who earn too much to qualify for public support, but too little to afford private cover. They are left exposed, paying out of pocket, and navigating a fragmented system while waiting for reforms that may still be years away.
As the NHI debate continues, this gap can no longer be treated as a future problem. It is a present reality.
The risk is that the debate remains stuck in ideology. That private healthcare is painted as inherently problematic, or that structural reform alone will resolve access challenges.
Neither is true.
Healthcare funding is always about trade-offs. There are no perfect systems, only different ways of balancing access, quality and affordability within finite resources.
If South Africa is serious about expanding access to healthcare, the debate must move beyond rhetoric and toward practical solutions.
These include using spare capacity in private facilities to treat public patients, and allowing medical schemes, through targeted regulatory reform, to offer affordable primary healthcare cover for people who are currently excluded. Done properly, this could unlock access to private healthcare for more than 10 million uninsured South Africans at a cost of as little as R400 per person per month. Combined with existing tax credits, the impact on a family’s take home pay could be close to negligible. By providing access to preventive and primary care through the private sector, they would reduce pressure on overcrowded public facilities and ease waiting times. Importantly, a strong focus on prevention and early intervention would reduce the need for costly hospitalisation over time.
Medical schemes are well placed to deliver these options, given the principles of social solidarity, community rating and cross-subsidisation that underpin their design. This approach is aligned with the Sustainable Development Goals and the core principles of universal health coverage, and could serve as a practical transitional step as South Africa moves towards the full implementation of National Health Insurance.
After all, the hardest question in healthcare is not what we would like to provide. It is what we can provide sustainably, fairly, and at scale.
*Naidoo is CEO of the Health Funders Association, an industry group that represents several medical schemes and medical scheme administrators in South Africa.
Note: Spotlight aims to deepen public understanding of important health issues by publishing a variety of views on its opinion pages. The views expressed in this article are not necessarily shared by the Spotlight editors.
Universal health coverage cannot succeed with fragmented systems, weak data, and largely symbolic participation. A recent court-ordered pause to NHI implementation offers a chance to build the foundations properly, argue Dr Haseena Majid and Professor Mogie Subban.
Implementation of the NHI Act has been delayed following a High Court order, by agreement between the parties, prohibiting the proclamation or implementation of its provisions until the Constitutional Court rules on challenges related to public participation.
Beyond the legalities, the pause reveals something more consequential. Universal health coverage cannot succeed on fragile administrative foundations.
If the NHI is to deliver equity, efficiency and quality care, the state must first confront the structural weaknesses that continue to shape large parts of South Africa’s health system. These include fragmented governance across national, provincial and local levels that weakens coordination and accountability; persistent shortages of health professionals that leave facilities understaffed and overburdened; and weak information systems that limit the state’s ability to track performance, allocate resources effectively and plan services based on reliable data.
The NHI Act can mandate pooled financing and new purchasing arrangements, but financing reform alone cannot fix fragmented governance, uneven data systems or inconsistent coordination between stakeholders. When reforms are layered onto unstable administrative systems, the result is not transformation but increased risk.
The eye health example
Eye health illustrates this challenge clearly. This is because it depends on coordination across many parts of the health system including clinics, skilled cadres such as optometrists and ophthalmologists, hospitals, NGOs and screening programmes. When these stakeholders do not work together effectively, patients fall through the gaps.
South Africa’s burden of chronic disease is rising, and with it preventable vision loss. The International Diabetes Federation estimates that around 2.3 million people in South Africa aged 20–79 live with diabetes, a condition that can affect the eyes and lead to vision loss and blindness if not detected early. Studies in South Africa have reported high rates of diabetic eye disease, including prevalence estimates of 39% in a tertiary diabetes clinic in Durban and around 25% in primary care settings in Tshwane.
These figures are not simply about eye disease. They reflect gaps in chronic disease coordination, screening coverage and referral systems. When diabetic eye screening is inconsistent, when referral pathways are unclear and when health data are incomplete, preventable vision loss becomes far more likely.
Cataract surgery, one of the most effective medical procedures available, is rightly prioritised. Yet provincial reporting continues to show significant surgical backlogs. While numbers fluctuate, the pattern remains consistent: demand continues to outpace coordinated capacity.
Vision challenges are also increasing as the population ages. A KwaZulu-Natal study reported presbyopia prevalence of 77% among examined adults. As the population grows older, near-vision impairment becomes not only a clinical concern but also one that affects productivity, mobility and independence.
Taken together, diabetes-related eye disease, cataracts and age-related vision decline illustrate a predictable and growing demand for eye-care services. The burden is clear, but the health system response remains uneven.
Only around 6–7% of optometrists practice in the public sector, while the majority work in private urban settings. Across the country, eye-care services are delivered through a mix of public facilities, private practitioners, NGOs, outreach surgical programmes and school screening initiatives. Yet there is no single national picture showing who is providing which services, where those services are located, and how well they are functioning. Government therefore does not consistently have a clear view of which partnerships are active, which communities are overserved or neglected, what equipment is functioning at facilities, or how the workforce is distributed relative to need. This is not a minor administrative gap, instead it is a governance failure with real consequences.
No clear view
Government cannot plan for what it cannot see. Data gaps and poor system visibility are creating blind spots that will paralyse even the best financing reforms. Without clear stakeholder mapping and infrastructure audits, planning becomes reactive. Procurement decisions become distorted and workforce deployment misaligned. Funding reform under the NHI may change how services are purchased, but if the underlying service network remains fragmented, inefficiencies will simply be redistributed.
The consequences extend beyond clinics. Children with uncorrected vision problems struggle at school. Adults with untreated diabetic eye disease risk losing income and economic stability. Older persons waiting for cataract surgery may lose mobility and independence. When health systems fail to coordinate care, the costs are first absorbed by households and later by the state through disability, preventable complications and lost productivity.
The NHI Act aims to improve equity and purchasing efficiency. But efficiency depends on knowing where services exist and where they are missing. Equitable access depends on understanding how infrastructure and human resources are distributed. Quality oversight depends on reliable data that allows performance to be monitored. What the NHI pause ultimately exposes is unfinished work in health-system governance. South Africa does not lack policy ambition. The country is widely recognised for progressive health policy. The challenge lies in fragmented implementation, limited visibility of service networks and uneven coordination across institutions.
A strategic choice
The Department of Health now faces a strategic choice. It can wait for the courts to resolve the legal process, or it can use this moment to strengthen the operational foundations needed for equitable reform.
Eye health presents a practical place to begin. It may not command the urgency of oncology, emergency medicine or infectious disease management, but that is precisely why it offers an opportunity to test workable solutions. Even under the best financing model, sustainable eye care depends on coordinated collaboration between public facilities, private practitioners, NGOs and community networks. A focused national pilot could map eye care services geographically, combining stakeholder mapping with infrastructure audits and workforce distribution analysis. This would strengthen planning in eye health while providing the system visibility that large-scale purchasing reforms like NHI depend on. The efficiency gaps are already known. What is needed now is coordinated implementation. If government can demonstrate that fragmented service environments can be mapped and coordinated within eye health, it will create a practical reform model for other strained areas of the health system.
Universal health coverage will not be secured simply by moving money differently. It will be secured by making the system visible, coordinated and accountable. The current pause has given us more time. What matters now is whether it is used to build the governance foundations that real reform requires.
*Dr Majid is a Postdoctoral Research Fellow at the College of Law and Management Studies, University of KwaZulu-Natal. Professor Subban is Academic Mentor and Public Governance Expert, at the College of Law and Management Studies, University of KwaZulu-Natal.
Note: Spotlight aims to deepen public understanding of important health issues by publishing a variety of views on its opinion pages. The views expressed in this article are not necessarily shared by the Spotlight editors.
The National Health Insurance (NHI) Act On Friday (20 February), it was reported that President Cyril Ramaphosa had put a halt on putting the NHI Act into effect, amid an array of legal challenges. Four days later, the Pretoria High Court granted an order to the same effect.
The NHI has probably been the most contentious piece of legislation passed in South Africa, and the developments since it was signed into law have been coming thick and fast. The promulgation, that is, putting the law into effect, of the NHI was long predicted to be the hardest part of getting this attempt at universal healthcare to work.
This latest court order restrains President Ramaphosa from any further work in promulgating the NHI Act – something which he had already announced he would do just a few days ago, as reported by BusinessTech. This represents something of a pause in the ongoing legal maelstrom – nothing can be decided until the court cases clear, according to an attorney’s statement on behalf of the President.
Almost as soon as the NHI was signed into law, an array of unions, hospitals, professional organisations and even the Western Cape government launched legal challenges. A ruling compelled the President to provide the records of his decision to sign the NHI into law. One key part governing where healthcare professionals could practice has already been struck down as unconstitutional by a July 2025 High Court ruling.
The lobby group AfriForum last week entered the fray with multiple challenges to the NHI’s constitutionality, aiming to force the government to scrap the NHI completely. A few days later, President Ramaphosa paused the NHI’s promulgation. This all came amidst discussion by the Department of Health into phasing out medical aid tax credits to begin the NHI Fund – which would squeeze many middle-class families out of being able to afford private healthcare. (For now at least, there is good news – just as QuickNews was typing this, it was announced that medical aid tax credits would be increased for 2026).
Experts and even the government itself have acknowledged that these legal challenges will further delay the already decades-long implementation of the NHI, and it appears that this has come to pass. Whether the NHI is modified to a workable version along the lines suggested by industry experts, or whether it is scrapped entirely and South Africa remains stuck with its deeply unequal public/private sector divide remains to be seen.
What is certain is that the NHI as originally envisioned simply isn’t affordable for South Africa – or even a wealthy developed country. The National Treasury seems to be aware of this, as suggested by its minimal allocations to the NHI Fund and medical aid tax credits being updated for this year’s budget.
With several important developments on the horizon, 2026 is set to be another eventful year in healthcare. Photo by Anna Shvets
19th January 2026 | By Marcus Low
From the limited rollout of a new HIV prevention jab to developments with new weight loss medicines, to high-stakes court cases relating to National Health Insurance (NHI), 2026 is set to be another tumultuous year in healthcare. Here are nine stories that Spotlight will keep a close eye on.
1. How will things go with the local rollout of a new HIV prevention jab?
Given the high rates of HIV in South Africa, the biggest HIV story this year is likely to be the rollout of a new HIV prevention jab at around 360 (roughly 10%) of South Africa’s public sector clinics. The jab, which contains the antiretroviral medicine lenacapavir, provides six months of protection against HIV infection at a time. It could be a gamechanger for people who, for whatever reason, struggle to take daily prevention pills. We will be tracking how and to whom the jab is made available and whether uptake meets expectations.
As we reported last year, work is also underway on a new lenacapavir formulation that could provide 12 months of protection per shot. We’ll be scouring journals and conference programmes for new data on this formulation.
2. Will we see better access to weight loss medicines?
The class of diabetes and weight loss drugs called GLP1-RAs have taken the world by storm in recent years. Until recently, drugs like semaglutide (brand names Ozempic or Wegovy) and tirzepatide (brand names Zepbound or Mounjaro) were only available as injections. The GLP1-RA market is, however, set to be upended by the introduction of some of these medicines in pill form. The United States Food and Drug Administration (FDA) recently registered a semaglutide pill for use for weight loss. Another weight loss pill called orforglipron is also expected to be registered this year. One big question is when these pills will be registered and made available in South Africa and at what price.
Another important GLP1-RA development this year will be the expiration of a key patent on semaglutide in India. This will open the door to generic manufacturers bringing their own versions of semaglutide to market – something that usually leads to substantial price reductions. We will be keeping a close eye on how this situation plays out and analysing what the implications are for people in South Africa.
3. Might we see earlier than expected findings from pivotal TB vaccine trials?
The one TB vaccine we have is over a hundred years old and only provides limited protection for kids. Several experimental vaccines are, however, currently being evaluated in late-stage clinical trials. Arguably, the most notable of these is the M72 vaccine, which is being assessed in a massive phase 3 study, partly conducted in South Africa.
While timelines suggest most of the key TB vaccine studies will not yet have anything to report this year, it is possible that we might see a surprise or two. Findings are sometimes reported early if it becomes apparent ahead of schedule that a medicine or vaccine is clearly working, or clearly not working, as the case may be. Whether or not we see findings this year, it is important to start thinking about what a rollout might look like in our health system should results be as good as hoped. The M72 vaccine had around 50% efficacy in phase 2 trials, so there is reason for optimism.
4. Will we see a concrete plan to address public sector healthcare worker shortages?
Arguably, the most important dynamic in South Africa’s public healthcare system today is that provincial health departments are not employing enough healthcare workers across multiple categories. One reason for this is simply that budgets have generally shrunk over the last decade – obviously corruption and mismanagement in several provincial departments have made things even worse. There was a glimmer of hope in last year’s budget in which we saw a meaningful upturn in health funding for the first time in years, but that was at best a good first step toward recovery. As we enter 2026, our understanding is that all of the nine provinces are still facing severe healthcare worker shortages.
More money for health in the next budget will certainly help, but there is a broader sense that government doesn’t really have a big picture vision for how to address the crisis. We do have a 2030 Human Resources for Health Strategy, but as with many such strategies, it seems to have so far gone largely unimplemented.
5. Will enablers be held accountable for corruption such as that at Thembisa Hospital?
One of last year’s big media moments was a Special Investigating Unit (SIU) press conference in which they described the extensive corruption said to have taken place at Thembisa Hospital. One snag, however, is that while the SIU can recoup funds and take matters to the Special Tribunal, the SIU does not conduct criminal prosecutions – though they can refer matters to the National Prosecuting Authority (NPA) for prosecution. Whether we will see successful NPA prosecutions relating to the Thembisa Hospital corruption is one of the year’s top questions.
Unfortunately, even when the SIU does sterling work and delivers cases to the NPA on a plate, there is no guarantee that the NPA will do its job. One depressing example is that of Buthelezi EMS. Last year, the Special Tribunal ordered Buthelezi EMS (and other companies with similar names) to pay over half-a-billion Rand back to the state. The SIU also referred a related matter to the NPA in 2024 for prosecution, but Spotlight understands that the NPA has rather mind-bogglingly decided to drop the matter.
6. Which, if any, senior health leaders will lose their jobs this year?
While we won’t have national or provincial elections this year, that is no guarantee that we won’t see any health leaders losing their jobs. Over the last two decades, there have after all been many examples of people being ousted between elections, be it for purely political reasons or due to corruption scandals.
Possibly the political leader in the health sector at greatest risk is KwaZulu-Natal MEC for Health, Nomagugu Simelane. Should the currently governing coalition of political parties in the province crumble, as it seems it might do, chances are several new MECs will be deployed, including for the health portfolio.
There is also an outside chance that the country’s top health official, Dr Sandile Buthelezi, Director-General for Health in the National Department of Health, might be forced to step down. As reported by AmaBhungane, Buthelezi played a central role in an “irregular” R836-million oxygen procurement process and is also “at the centre of aHawks investigation into allegations that he solicited a R500 000 bribe”. Our understanding is that Buthelezi has not been charged and that in the absence of charges he will stay in the job.
7. What will happen in the landmark NHI court cases?
Despite a new call for dialogue from Finance Minister Enoch Godongwana, chances for a political settlement over National Health Insurance (NHI) remains very low. The bottom line remains that Health Minister Dr Aaron Motsoaledi refuses to yield an inch on the version of NHI described in the Act and President Cyril Ramaphosa is not willing to force the matter.
Instead, it seems the battle over NHI will this year be fought mainly in the courts. At our count, there are at least eight cases challenging the NHI Act, parts of the Act, or the process resulting in the Act. A first development to look out for is whether or not some of the cases will be combined and heard together. In case you missed it, last year we published a two-part series in which we tried to pin down the issues on which these court cases are likely to turn (see part 1 and part 2).
While we will cover the NHI court cases in some depth, we will also try to foster constructive discussions on health reforms on our opinion pages and in our analysis. In our view, it is dangerously limiting to reduce the debate over South Africa’s healthcare reforms to a simple binary of whether one is for or against NHI.
8. What will be left of the FDA, NIH, and CDC by the end of 2026?
It used to be the case that United States Food and Drug Administration (FDA) decisions and health advice from the United States Centres for Disease Control and Prevention (CDC) carried a lot of weight around the world. In recent months, however, there have been increasing signs of political interference at these institutions and a turn away from evidence-based policy making. It seems inevitable that we will see more of the same in 2026 and the credibility of both the CDC and probably also the FDA will be further diminished.
Similarly, the US National Institutes for Health (NIH) has been the world’s leading funder of health research for many years. But as with the CDC, the work of the NIH has been overly politicised over the last year and its reputation for rigour and scientific excellence has already been severely degraded. As with the FDA and CDC, the outlook is bleak.
9. How well will SA and other countries recover from last year’s US aid cuts?
With the dust settling after last year’s severe and abrupt cuts to US healthcare aid and US funding for medical research, the longer-term impacts of those cuts in South Africa and neighbouring countries should become clearer this year. Among others, we will get the first reliable estimates of key HIV and TB indicators for 2025 (reliable figures for a specific year are typically only published in the subsequent year). New HIV estimates from the Thembisa mathematical model (Spotlight’s preferred source for HIV estimates) should be out around the middle of the year, while new World Health Organization (WHO) TB estimates are usually released in November.
Last year Motsoaledi was widely criticised by activists for underplaying the seriousness of the cuts for South Africa’s HIV response and the scale of specialised services and capacity that was destroyed here. Eventually some extra funds were made available in response to the cuts, but it amounted to only a small fraction of what was lost. The harsh reality is that in some places the aftermath of the aid cuts will be felt for years to come.
At an international level, we are also not convinced that a clear roadmap has been set out for building back better after US withdrawal, though we’d be happy to be proven wrong. What is clear though is that entities like the WHO and UNAIDS are facing unprecedented financial and political pressures – it seems possible that UNAIDS will no longer exist a year from now. Much reform has already been undertaken at the WHO. By the end of the year, we should have some sense of whether things have stabilised and whether a coalition of willing nations is truly committed to keeping the WHO and multilateralism in health alive.
We have outlined only nine health issues in the above, but there are of course many more questions that we could have added to this list. Some of those include:
Whether we will see meaningful improvement in the South African government’s response to non-communicable diseases such as diabetes, cancers, and mental health conditions.
How well implementation of South Africa’s latest TB recovery plan is going, and in particular how we are doing against the target of testing five million people in 12 months.
How climate change will impact people’s health and whether the South African government is prepared for it.
Whether South Africa will see real progress in addressing antimicrobial resistance. After adopting a good policy a few years ago, it appears momentum has been lost.
Whether the state will start taking xenophobia in the healthcare system and around clinics and hospitals more seriously, as a recent court judgment requires it to do.
Whether we will see legislation introduced amending the Patents Act in line with a policy adopted by government in 2018 and whether we’ll see progress on the much-delayed State Liability Bill, which should have relevance for the state’s vulnerability to medico-legal claims.
Whether we will see concrete steps forward with the new electronic health records and data systems government is developing.
What progress we might see with the local production of vaccines and pharmaceuticals – one of the areas in which we are quite optimistic, despite the lack of coherent and enabling government policy.
What impact AI will, or will not, have in our healthcare system this year.
Are there issues not mentioned here that you think Spotlight should cover in 2026? Let us know by commenting below this article or by tagging us on BlueSky.
It is not a stretch to say that the NHI Act has been one of the most controversial pieces of legislation in post-apartheid South Africa.
Since President Cyril Ramaphosa signed it into law in May 2024, just two weeks ahead of the national and provincial elections, at least nine different court cases have been launched against the Act, or specific provisions in the Act. None of those cases have made it through the courts and it seems likely some might be combined.
In one preliminary to the bigger court battles, the North Gauteng High Court in Pretoria ordered Ramaphosa to provide the record of his decision to sign the act, but the President is challenging that order.
A subtext to the torrent of court cases is the sense that it is only through litigation that the NHI Act might be scrapped, or that some of the most controversial provisions in it might be repealed. The alternative to litigation, political compromise, for now seems dead in the water. There was some hope for such compromise around a year ago when Business Unity South Africa and several healthcare worker groups pushed government for a change in course – but while the Presidency seemed open to considering changes, the health minister did not, and eventually the ANC, and government with it, decided to buckle down behind their current NHI plans.
The door to political compromise could of course reopen should the balance of political power in the country change – as it will surely do after the 2029 elections, if not earlier.
To the courts then
There has been much media coverage of the various court cases challenging the NHI Act. Understandably, a lot of the public statements were aimed at drumming up public support for the various points of view. In the end, the courts will hopefully look past the rhetoric and politicking and judge the cases on their merits.
This is why in recent months Spotlight put substantial resources into combing through seemingly endless court papers and chatting to a variety of lawyers in an attempt to sift the wheat from the chaff. As with many other court cases we’ve reported on, we suspect the various NHI-related cases will in the end turn on just a few key legal questions. In a special two-part series, we tried to pin down what these key legal questions are likely to be – you can see part 1 here and part 2 here. (Thank you to the three lawyers we quote in the article, as well as those who shared their views, but opted not to be named and quoted.)
In our view, this crystallisation of the legal case against the NHI Act, and/or specific provisions in the Act, is the most notable NHI-related development this year. After all, a major ruling against the Act could make much else moot.
Other NHI developments
Meanwhile, the Department of Health is moving ahead on the assumption that NHI will be implemented as envisaged in the Act. The first formal step towards setting out the proposed governance structure and processes of the NHI Fund is underway with draft regulations that were published in the Government Gazette in March. Amongst others, the regulations provide for the appointment of the board of the NHI Fund, the fund’s chief executive officer, and for a benefits advisory committee and a healthcare benefits pricing committee. In the background here is the fact that, until the NHI Fund has been established as a public entity, it cannot be awarded a budget by parliament.
One source of funding for NHI could be the phasing out of medical scheme tax credits. This is according to a presentation by the National Health Department’s NHI lead, Dr Nicholas Crisp, who was addressing the Standing Committee on Appropriations in the National Assembly. The presentation notes that medical scheme tax credits could raise as much as R34bn for the NHI Fund by 2027/28. At the moment, eligible beneficiaries receive medical scheme tax credits to the value of R364 per month for the primary member, R364 for the first dependant, and R246 for each additional dependant. The rough idea is that tax credits would first be phased out for high-income earners. This would eventually be followed by the state scrapping medical scheme subsidies to civil servants.
But Finance Minister Enoch Godongwana seems unconvinced. He told BusinessDay: “It’s actually an attack on the middle class”.
And indeed, the proposed scrapping of medical aid subsidies has added fuel to suggestions that government is intentionally undermining the viability of private healthcare in South Africa. A set of recommendations on how to better regulate the country’s private healthcare sector remains largely unimplemented six years after being published. Government did publish draft regulations for tariff determination in the private sector in February, but, as we recently reported, those draft regulations have now been withdrawn. In fact, those draft regulations were so poorly thought out that one wonders whether they were a serious attempt at addressing the issue in the first place.
According to Crisp’s presentation, NHI could take “10, 15 or more” years to implement. There is some welcome realism in this. Rather absurdly, Section 57 of the NHI Act still states that it will be introduced in two phases, between 2023 and 2026, and between 2026 and 2028.
Several experts have suggested to Spotlight that, mainly for financial reasons, NHI is essentially dead in the water and that the more serious people in the government and the ANC know this. Few are however willing to say this publicly. Others, like Crisp and Health Minister Dr Aaron Motsoaledi, would of course beg to differ, and mean it.
Not the only solution
One thing that should not get lost in all this is that things really do need to change. Apart from being extremely unequal, much of the healthcare system in South Africa is deeply dysfunctional. But Motsoaledi is wrong when he suggests that the specific system set out in the NHI Act is the only possible solution. As we’ve previously argued, there are other viable paths to universal health coverage, even if the current set of leaders in the ANC refuses to seriously consider them.
One of the great tragedies of NHI is that for all the noise, we have never really had an informed public debate about the policy options and the reasons for going with one set of health reforms rather than another. There were few things as depressing as watching members of parliament’s portfolio committee for health reducing someone’s nuanced and constructive feedback on the Bill to a simple question of whether someone is for or against NHI. The ANC of course had a majority in parliament prior to the 2024 elections, so maybe there was a sense that they did not need to listen and do the hard work of engaging and bringing people along with them.
Either way, it now seems likely that in 2026, the courts will have to make one or more landmark rulings that will determine the future of NHI. We have some idea of what the key issues will be on which those cases will turn, but as to how the courts will decide, your guess is as good as ours.
